BH Healthcare Consulting Group – Provider Intake Form
Share your practice details, services, insurance, and support needs so we can follow up and assist with next steps.
Practice Information
Practice Name
*
Primary Contact Name
*
Role / Title
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Addresses
Website
States Currently Served
How Long Has the Practice Been in Operation?
*
Less than 1 Year
1–3 Years
4–7 Years
8+ Years
Provider & Service Details
Services Offered
*
Occupational Therapy
Physical Therapy
Speech Therapy
Pediatric Social Work
Applied Behavior Analysis (ABA)
Other
Number of Active Providers
*
Number of Active Clients
*
Current EHR/EMR System
*
Insurance & Credentialing
Current insurance plans contracted with
Current network status
*
In-Network
Out-of-Network
Both
Credentialing support needed
*
Yes
No
If yes, which payers?
Number of providers needing credentialing support
1
2–5
6–10
10+
Pending credentialing applications
Yes
No
If yes, list pending applications
Authorizations & Claims
What support do you need?
*
Authorization Management
Eligibility & Benefits Verification
Claim Submission
Claim Denial Management
Appeals
All of the Above
Average monthly claim volume
Current denial rate, if known
Approximate monthly insurance revenue
Under $25,000
$25,000–$50,000
$50,000–$100,000
$100,000–$250,000
Over $250,000
Revenue Cycle & Operations
Current Billing Process
*
In-House Billing Team
Single Biller
Outsourced Billing Company
Owner Managed
Other
Biggest Administrative Challenges Right Now
Practice Goals
Top 3 goals for the next 6–12 months
*
Practice Goals - Additional Notes
Consent & Submission
Preferred method of follow-up
*
Email
Phone
Text
Best time to contact
*
Morning
Afternoon
Evening
Signature / typed name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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